The failure of a Dallas hospital's electronic medical record system to flag a man who turned out to be infected with the Ebola virus underscores how clunky, outdated and inefficient health information systems typically are in the U.S., a medical IT CEO charged Friday.
"The worst supply chain in our society is the health information supply chain," said Bush. . . "It's just a wonderfully poignant example, reminder of how disconnected our health-care system is."
"It's just a very Stone-Age sector, because it's very conservative," Bush said. "Hospital health care is still in the era of pre-Internet software."
"The hyperbole should not be directed at Epic or those guys at Health Texas," Bush said. "The hyperbole has to be directed at the fact that health care is islands of information trying to separately manage a massively complex network . . . People trying to recreate their own micro-Internet inside their own little biosphere . . . that'll never, never, never be excellent," Bush said. "There's no 'network effect' in health care today."
The hospital Thursday night said when Duncan was first examined Sept. 25 by a nurse, he was asked a series of questions, including whether he had traveled outside of the U.S. in the prior month.Of course, that particular problem at that particular hospital is now fixed. But . . .
"He said that he had been in Africa," the hospital said in a statement. "The nurse entered that information in the nursing portion of the electronic medical record."
But it turns out that answer—which could have alerted doctors of the possibility Duncan had Ebola—was not relayed electronically to them because of "a flaw" in the way doctors' workflow portions of the electronic health records interacts with the nursing portions of the EHR.
"In our electronic health records, there are separate physician and nursing workflows," the hospital said. "The documentation of the travel history was located in the nursing workflow portion of the EHR, and was designed to provide a high reliability nursing process to allow for the administration of influenza vaccine under a physician-delegated standing order. As designed, the travel history would not automatically appear in the physician's standard workflow."
"We have made this change to increase the visibility and documentation of the travel question in order to alert all providers," Texas Health said. " We feel that this change will improve the early identification of patients who may be at risk for communicable diseases, including Ebola."Mr. Bush was quite tactful, but the implication of his statement is truly astounding. He is saying, perhaps not quite in so many words, that the IT department of the Texas Health hospital in Dallas, by poorly implementing (my opinion, not necessarily his) poorly designed (again, my opinion, not necessarily his) software, could be responsible for a disaster. This glitch has potentially allowed Ebola to spread further than it would have had Mr. Duncan been put immediately into confinement upon his first presentation. To be fair, the patient had been in contact with others before his first ER trip; still, we can assume he had more interaction with more people than he might have otherwise. We can only wait and see how many of his family members and acquaintences come down with the often-fatal disease. I should also mention that the ER physician should probably have thought to ask about foreign travel when presented with a feverish African national presumably speaking with an accent.
Bush noted that typically when problems like the flaw in Texas Health's EHR system are fixed, "they're fixed only at the place where they appeared."
"Those mistakes are happening constantly," Bush said.
But, "philosophically I think hospitals should get out of the business of trying to program computer systems, and expand in the business of treating patients. But that's a standard thing that goes wrong with millions of configurations" of EHRs, he said.
Faulkner, an influential Obama campaign finance bundler, served as an adviser to David Blumenthal. He’s the White House health information technology guru in charge of dispensing the federal electronic medical records subsidies that Faulkner pushed President Obama to adopt. Faulkner also served on the same committee Blumenthal chaired.I'm straying a little off-topic here, but I think it is unlikely in the extreme that Epic will shoulder even the slightest blame for Mr. Duncan's Dallas destruction. After all, as we say in the trade, PBKAC, Problem (was) Between Keyboard and Chair. In other words, it wasn't Epic's fault that whatever IT employee or committee failed to connect the dots and the map the critical foreign travel field from the nurses' intake screen to the doctors' review screen. Oops. So sorry.
Cozy arrangement, that.
Lawyers for the nation’s largest flight-attendant union argued in federal court Friday to effectively reinstate a government ban on the use of electronic devices during takeoffs and landings.ONE tablet flew, and we have to take everyone's away. How do we know it wasn't thrown?
The Association of Flight Attendants-CWA is suing the Federal Aviation Administration, saying the agency notice last year that paved the way for fliers to use their devices throughout flights violated federal regulations that require passengers to stow all items during takeoffs and landings.
Justice Department lawyers representing the FAA say the agency’s guidance, which permitted fliers to keep smaller devices in their hands during all phases of flight, doesn’t violate the stowage rule because small devices aren’t governed by it. The two sides argued the case Friday to a three-judge panel with the U.S. Court of Appeals for the D.C. Circuit. . .
Attorney Amanda Duré, who is representing the attendants union, said that since the policy change, many fliers have stopped listening to attendants’ emergency announcements and, in at least one incident, a tablet became a projectile during turbulence. The union also is concerned the devices could impede passengers’ exit from an aircraft during an emergency.
1. Coded hand gesturesCoffee, Tea, or Dalai?
Flight attendants "employ all sorts of unofficial methods and codes" to deal with difficult fliers, reports Emma Messenger at the Daily Mail. A "subtle wag of a finger" behind someone's head means that he's lecherous and may get handsy (or worse) with the staff. To alert colleagues that a passenger is drunk, attendants cross their fingers over the hospitality cart.
2. High winds
At the end of a demanding flight, writes David Sedaris in The New Yorker, some attendants indulge in the peevish practice of "cropdusting" — silently passing wind as they walk down the aisle making their final checks. "Reclined in their seats, heads lolling to the side ... airplane passengers are prime fart targets," comments Maureen O'Connor at Gawker.
3. Dirty drinks
Ellen Simonette — author of Diary of a Dysfunctional Flight Attendant: The Queen of Sky Blog — reminisces in The New York Times about the time a colleague took revenge on a loudmouthed passenger by making him "a very special drink" in the privacy of the galley, rubbing the rim of his glass on the plane's "filthy floor" before serving it up with a "devious smile."
4. Abusing their powers
We've all seen the seat-belt sign light up in midflight, though there isn't a hint of turbulence. Blame your attendants, says the Daily Mail's Messenger, who often switch it on so they can "have a nice cup of tea and gossip in peace."
5. Starting a blog
Countless flight attendants vent about passengers by blogging anonymously. Dubai-based blogger Tampax Towers recently railed against fliers who hold up security lines by wearing metal-studded jeans, while, over at These Wings Talk, a catty account of an experience with a "One-Eyed Cyclops Passenger" makes for surprising reading.
Dalai's note: A piece by Dr. Richard Gunderman posted on TheHealthcareBlog.com. It is unclear whether or not Dr. Gunderman's "discovery" is a real document or not. Still, it would seem to explain a lot of what we are seeing in healthcare today...
During this tech boom, is it a coincidence that the tech savvy San Francisco Giants are in the World Series for the third time since 2010? In this post, we take a look at the relationship of technology, leadership, big data analytics, and baseball. In particular, we explore how Major League Baseball manages its player/patient population, and the trends they are following since converting players from paper medical records to EHR.
Baseball teams are very secretive about how they use their data. Teams, like the San Francisco Giants, employ a slew of data analysts and data tools, but every team is reluctant to share how data is used, and where they derive insights. According to the 2014 SABR Analytics Conference, the new frontier of baseball data is not just about scouting players, but keeping players healthy and injury-free. The new area of research, just in in its infancy, is marrying baseball statistics with medical injury research.
Medical analysts are the new data darlings of baseball operations.
Chris Marinak, Sr. Vice President of Major League Baseball, implemented MLB’s switch to electronic medical records, and believes medical injury research will provide new insights over the next five or ten years,
I actually joined MLB in 2008, and I was shocked to see that we didn’t have a system for tracking injuries or medical information at a de-identified level. We were literally keeping a lot of paper documents and putting them into a filing cabinet. It was time for us to get into the 21st century.
So starting in the 2010 season, we rolled out an electronic medical records system working with the players’ association that allows our medical staff to enter in medical information on every single player injury and the treatments that those players get. And then that information is all stored in one place, so that when you go from one team to the next, it flows along with you.
Marinak says the ancillary benefit is that MLB now has an injury tracking system where they can track trends in the industry.
This data is analyzed at a de-identified level to find the drivers of lost time, and the injuries keeping players off the field. “So we can hopefully keep them healthier,” according to Marinak.
Baseball is a sport that has always been hungry for statistics. Sabermetrics, the study of baseball’s in-game play, has been around since the middle of the 20th century. But in 2002 and 2003, Sabermetrics became “Moneyball” as the Oakland As advanced to the playoffs with their analytic approach to assembling a competitive team, despite a lack of competitive dollars.
With the advent of new technologies, PITCHf/x data and Sportsvision video in 2006, the world of baseball was set to explode with big data and predictive analytics. Detailed data became accessible for every hit and pitch in a game.
Batting and pitching biomechanics also started to be video analyzed at the high school level. In 2009, my son clocked an official bat speed of 101 miles per hour, one of the fastest recorded bat speeds in the country for any amateur or professional player.
Bat speed is recorded via a static ball test, hitting off of a tee; exit speed is recorded hitting a pitched ball.
An injury sidelined his play, so he started experimenting with this new PITCHf/x data. His early web-based program would let you compare MLB pitchers and batters, and team matchups. Having baseball experience would help him provide insights for an individual player’s performance enhanced by data visualizations like heat maps.
Although PITCHf/x stated its data could not be used for commercial purposes, it didn’t take long for the financial world to play ball – Bloomburg Sports was born in 2011. The company’s latest technology (recently sold) has the capability to create every imaginable data point from video captured from play performance, whether that video is captured live or from a stream.
Do you want to know how many times a player licks his lips before fielding a ball? – Dan Cohen, Bloomberg Sports
Dr. Glenn Fleisig of the American Sports Medicine Institute says they look at what a person’s body is doing and that’s what biomechanics is, “Tracking where the ball went is all good, but we look at how did their body get there. The new thing teams are embracing is biomechanics.” More information will come from wearable tech and self-tracking technologies.
MLB is doing a lot more tracking of player movements utilizing Trackman and through studies at MIT. Marinak says having more of that information publicly available will be important to innovation, but right now it’s just too big, “A game’s worth of data in Trackman is 7 terabytes. So we’re talking about big data at a massive scale.” He cautions that how this data is treated will be different because it is medical information, and keeping a player’s medical information needs to be private.
Dr. Stan Conte (formerly with the SF Giants and now with the Los Angeles Dodgers) is a leading expert in medical injury research in baseball. He says they focus on “changes” in the data. He explains medical data is dirty data, so it is very difficult to analyze.
The data is getting better, and with more data, we’ll be able to go into areas that we hadn’t thought about before. – Dr. Stan Conte
But now that PITCHf/x also tracks every defensive play, it has been reported that the San Francisco Giants do defensive shifts better than all MLB teams. Is the team’s proximity to Silicon Valley, and its innovative CIO Bill Schlough, its World Series advantage? Or is it their overall focus on innovation?
The San Francisco Giants are dedicated to enriching our community through innovation and excellence on and off the field.
In 2004, the SF Giants were the first to offer Wi-Fi throughout their stadium. Today, approximately 35% of fans are online at games. The stadium’s “fat pipe” allows fans to easily upload content via the Giants app or social channels like Faceboook, Twitter, and Instagram.
In 2009, SF Giants CIO Bill Schlough introduced dynamic ticket pricing (DTP), allowing the price of game tickets to go up or down depending on popularity and availability. Other teams now use DTP, and the idea has spread to restaurants, movie theaters, and the performing arts.
— #OctoberTogether (@SFGiants) June 24, 2014
This year, the SF Giants opened a 4,320 sq. ft. edible garden and restaurant, affectionately called the “kale garden”, that sits overlooking center field. In addition to providing healthy fare for fans and players, the innovative garden will be used as an open-air classroom for students during the Giants’ off-season, where Bay Area youth will go to learn about sustainability, urban farming and healthy eating.
Gaining respect early as a technology leader was key for Schlough’s career, as the Giants let him run his own department with the ease and precision he wanted to do it in. It’s tremendous the impact Schlough has had on the Giants, but eventually that impact will affect the MLB as a whole. – Justin Kasser
Now, let’s play ball!
First, do no harm.
Four simple words that are synonymous with healthcare. It’s a principle that everyone in the industry – not just physicians – should adhere to.
So shame on us all for our part in allowing an EHR vendor to shut off a practice’s access to their patients’ medical records and for recklessly putting patients at risk.
Background: Full Circle Health Care in Maine purchased an EHR from HealthPort in 2010. Originally the maintenance fees were $300 a month. A few months later CompuGroup Medical purchased HealthPort and increased the maintenance fees to $2,000 a month. The practice protested the price increase and claimed CompuGroup failed to deliver hardware upgrades that had been paid for. The parties spent several months arguing and for 10 months the practice did not pay its maintenance bills. Finally in July, CompuGroup shut off the practice’s access to its medical records.
The details as to why the fees jumped so much and whether CompuGroup had the legal right to do so are a little unclear. What is clear is that multiple parties are at fault for allowing such a mess to occur.
Let’s start with the government, which created the HITECH program and promised thousands of dollars for providers willing to adopt and meaningfully use EHRs. Though the objectives were admirable, CMS failed to adequately address all the “what if” scenarios in its rush to move the program forward. The legislation and final rule provide no guidelines for protecting patient records in the event of a vendor/provider disagreement, financial hardship, or business discontinuance. Undoubtedly we’ll see plenty more disputes like this one in the coming years.
The practice also gets a share of the blame. The owner should have invested in legal advice before signing a $72,000 contract for something as critical as an EHR system. Did she skip this step in her haste to achieve Meaningful Use and earn incentive payments? Furthermore, even if she disputed the increase in maintenance pricing, shouldn’t she, at a minimum, have continued paying the $400 a month fee she believed was the correct amount? Perhaps the vendor would have been more willing to come to an acceptable agreement if she hadn’t stopped paying altogether.
CompuGroup, of course, looks like the really bad guy here. The multi-national company has annual revenues of about $600 million. Did they really need to pull the plug on this practice over a piddling $40,000? The company’s general counsel says the situation is similar to an electric company shutting off power when a customer fails to pay. Perhaps, but many municipalities and some states have laws that prohibit the discontinuance of services under certain conditions, such as in extreme cold weather or when a child or sick person is in residence. In other words, there are laws to protect consumers against potentially harmful actions. (See: EHRs And The Law: When Interoperability Isn’t a Choice)
Which brings us to the seemingly forgotten patient, who arguably is – or should be – the owner of his or her own record. We do have federal and state laws that give patients the right to access and inspect their medical records. Perhaps the practice’s 4,000 patients should all send CompuGroup a written request for a copy of their records. Maybe an attorney who is smarter than me should look into that.
Until the mess is settled, we have a practice seeing patients without the benefit of medication and allergy lists, details on previous treatments, or lab and test results. And everyone involved is hoping that no patients are harmed.
Whether our role in healthcare is policy maker, technology developer, provider, or HIT geek, we really need to do better.
Industrial designer Marc Harrison suffered a brain injury while sledding when he was 11-years old. The injury and years of rehabilitation would provide Harrison with insight and inspiration for his future work in industrial design.
Harrison would go on to develop the philosophy of Universal Design – the idea that products should be developed for people of all abilities, not just for people of average size, shape, and ability.
Harrison’s study of people with disabilities led to the iconic design of the Cuisinart food processor, a design still relevant today after more than 40 years. The simple, clean design would also come to be a major influence for Steve Jobs in the development of the Macintosh computer.
If you put the original Mac in 1984 side-by-side with an early ’80s Cuisinart, the influence on the physical design of the Mac is immediately obvious. Not only is the Mac designed with software for accessibility and more universal design, but its physical design had this perhaps unknown influence as well. – Dean Karavite
I learned about Harrison from an exceptional interview with Dean Karavite, a Human Interaction Specialist in Clinical Informatics at Children’s Hospital of Philadelphia. Dean was interviewed by Whitney Quesenbery, co-author of the book, “A Web for Everyone”.
It is important to point out that people with disabilities are not all people in poor health.
People with disabilities use the health care system a lot and in many different ways. –Whitney Quesenbery
Among study participants with various levels of disability, Dean found that people with the highest level of needs – those also with many chronic conditions – were the source of “the most detailed, sophisticated, and innovative ideas on what an accessible PHR should do.”
Understanding what users want and the problem the application will solve should be the first step in any development process. How does user-centered design firm IDEO find people to interview for needfinding? While it is great to speak with average users, the most interesting interviews come from “extreme users.” This idea of extreme users is also explored in “Just Ask: Integrating Accessibility throughout Design” by Shawn Henry.
As part of our project exploring accessible Personal Health Records, one of the methods we have applied was performing a survey with 150 people with different disabilities. In that survey, we had our participants rate over 20 health topics in two ways.
First, in terms of how important the particular topic was to their health and healthcare, and second, their current level of satisfaction with a particular issue or topic.
The number one, most highly rated issue in terms of importance was the ability to share medical information between different providers’ offices, and hospitals.
The real underlying issue here isn’t just the transfer of data, but care coordination, which is the collaboration, not just communication, but collaboration between multiple healthcare providers. – Dean Karavite interview with Whitney Quesenbery
Another part of the “Accessibility Designs” project looked to assess the current state of PHR systems for accessibility, functionality and usability.
Unfortunately, vendors were reluctant to participate.
These results came from systems project team members used to manage their own health including a hospital PHR, an ambulatory PHR, and a consumer PHR.
According to the project, “The hospital PHR was the least functional and least usable, yet was the most accessible. Meanwhile the ambulatory PHR was the most functional and most usable, yet failed to meet basic accessibility standards. The consumer PHR was quite usable despite failing to meet accessibility criteria, and failed one crucial accessibility requirement: the entry of dates by people with visual and/or physical disabilities, a critical action required by almost every task managed by the system.”
Many of the technologies used today are the result of work used to meet the needs of people with disabilities:
“For example, touch screens, on-screen keyboards with word prediction, zoomable displays, speech recognition, text-to-speech. Think about it. It took about 10 to 15 years, and now we all have it on our computers, our phones and other devices, and we absolutely love it.” – Dean Karavite
Get out of your little box and look for inspiration all over the place.
Good ideas can come from anywhere!
Healthcare executives are continuously evaluating the subject of RFID and RTLS in general. Whether it is to maintain the hospitals competitive advantage, accomplish a differentiation in the market, improve compliance with requirements of (AORN, JCAHO, CDC) or improve asset utilization and operating efficiency. As part of the evaluations there is that constant concern around a tangible and measurable ROI for these solutions that can come at a significant price.
When considering the areas that RTLS can affect within the hospital facilities as well as other patient care units, there are at least four significant points to highlight:
Disease surveillance: With hospitals dealing with different challenges around disease management and how to handle it. RTLS technology can determine each and every staff member who could have potentially been in contact with a patient classified as highly contagious or with a specific condition.
Hand hygiene compliance: Many health systems are reporting hand hygiene compliance as part of safety and quality initiatives. Some use “look-out” staff to walk the halls and record all hand hygiene actives. However, with the introduction of RTLS hand hygiene protocol and compliance when clinical staff enter or use the dispensers can now be dynamically tracked and reported on. Currently several of the systems that are available today are also providing active alters to the clinicians whenever they enter a patient’s room and haven’t complied with the hand hygiene guidelines.
Locating equipment for maintenance and cleaning:
Having the ability to identify the location of equipment that is due for routine maintenance or cleaning is critical to ensuring the safety of patients. RTLS is capable of providing alerts on equipment to staff.
A recent case of a hospital spent two months on a benchmarking analysis and found that it took on average 22 minutes to find an infusion pump. After the implementation of RTLS, it took an average of two minutes to find a pump. This cuts down on lag time in care and can help ensure that clinicians can have the tools and equipment they need, when the patient needs it.
There are also other technologies and products which have been introduced and integrated into some of the current RTLS systems available.
There are several RTLS systems that are integrated with Bed management systems as well as EHR products that are able to deliver patient order status, alerts within the application can also be given. This has enabled nurses to take advantage of being in one screen and seeing a summary of updated patient related information.
Unified Communication systems:
Nurse calling systems have enabled nurses to communicate anywhere the device is implemented within the hospital facility, and to do so efficiently. These functionalities are starting to infiltrate the RTLS market and for some of the Unified Communication firms, it means that their structures can now provide a backbone for system integrators to simply integrate their functionality within their products.
In many of the recent implementations of RTLS products, hospital executives opted to deploy the solutions within one specific area to pilot the solutions. Many of these smaller implementations succeed and allow the decision makers to evaluate and measure the impacts these solutions can have on their environment. There are several steps that need to be taken into consideration when implementing asset tracking systems:
• Define the overall goals and driving forces behind the initiative
• Develop challenges and opportunities the RTLS solution will be able to provide
• Identify the operational area that would yield to the highest impact with RTLS
• Identify infrastructure requirements and technology of choice (WiFi based, RFID based, UC integration, interface capability requirements)
• Define overall organizational risks associated with these solutions
• Identify compliance requirements around standards of use
RFID is one facet of sensory data that is being considered by many health executives. It is providing strong ROI for many of the adapters applying it to improve care and increase efficiency of equipment usage, as well as equipment maintenance and workflow improvement. While there are several different hardware options to choose from, and technologies ranging from Wi-Fi to IR/RF, this technology has been showing real value and savings that health care IT and supply chain executives alike can’t ignore.
It was not long after mankind invented the wheel, carts came around. Throughout history people have been mounting wheels on boxes, now we have everything from golf carts, shopping carts, hand carts and my personal favorite, hotdog carts. So you might ask yourself, “What is so smart about a medical cart?”
Today’s medical carts have evolved to be more than just a storage box with wheels. Rubbermaid Medical Solutions, one of the largest manufacturers of medical carts, have created a cart that is specially designed to house computers, telemedicine, medical supply goods and to also offer medication dispensing. Currently the computers on the medical carts are used to provide access to CPOE, eMAR, and EHR applications.
With the technology trend of mobility quickly on the rise in healthcare, organizations might question the future viability of medical carts. However a recent HIMSS study showed that cart use, at the point of care, was on the rise from 26 percent in 2008 to 45 percent in 2011. The need for medical carts will continue to grow; as a result, cart manufacturers are looking for innovative ways to separate themselves from their competition. Medical carts are evolving from healthcare products to healthcare solutions. Instead of selling medical carts with web cameras, carts manufacturers are developing complete telemedicine solutions that offer remote appointments throughout the country, allowing specialist to broaden their availability with patients in need. Carts are even interfaced with eMAR systems that are able to increase patient safety; the evolution of the cart is rapidly changing the daily functions of the medical field.
Some of the capabilities for medical carts of the future will be to automatically detect their location within a healthcare facility. For example if a cart is improperly stored in a hallway for an extended period of time staff could be notified to relocate it in order to comply to the Joint Commission’s requirements. Real-time location information for the carts could allow them to automatically process tedious tasks commonly performed by healthcare staff. When a cart is rolled into a patient room it could automatically open the patient’s electronic chart or give a patient visit summary through signals exchanged between then entering cart and the logging device kept in the room and effectively updated.
Autonomous robots are now starting to be used in larger hospitals such as the TUG developed by Aethon. These robots increase efficiency and optimize staff time by allowing staff to focus on more mission critical items. Medical carts in the near future will become smart robotic devices able to automatically relocate themselves to where they are needed. This could be used for scheduled telemedicine visits, the next patient in the rounding queue or for automated medication dispensing to patients.
Innovation will continue in medical carts as the need for mobile workspaces increase. What was once considered a computer in a stick could be the groundwork for care automation in the future.
This has been an eventful year for speech recognition companies. We are seeing an increased development of intelligence systems that can interact via voice. Siri was simply a re-introduction of digital assistants into the consumer market and since then, other mobile platforms have implemented similar capabilities.
In hospitals and physician’s practices the use of voice recognition products tend to be around the traditional speech-to-text dictation for SOAP (subjective, objective, assessment, plan) notes, and some basic voice commands to interact with EHR systems. While there are several new initiatives that will involve speech recognition, natural language understanding and decision support tools are becoming the focus of many technology firms. These changes will begin a new era for speech engine companies in the health care market.
While there is clearly tremendous value in using voice solutions to assist during the capture of medical information, there are several other uses that health care organizations can benefit from. Consider a recent product by Nuance called “NINA”, short for Nuance Interactive Natural Assistant. This product consists of speech recognition technologies that are combined with voice biometrics and natural language processing (NLP) that helps the system understand the intent of its users and deliver what is being asked of them.
This app can provide a new way to access health care services without the complexity that comes with cumbersome phone trees, and website mazes. From a patient’s perspective, the use of these virtual assistants means improved patient satisfaction, as well as quick and easy access to important information.
Two areas we can see immediate value in are:
Customer service: Simpler is always better, and with NINA powered Apps, or Siri like products, patients can easily find what they are looking for. Whether a patient is calling a payer to see if a procedure is covered under their plan, or contacting the hospital to inquire for information about the closest pediatric urgent care. These tools will provide a quick way to get access to the right information without having to navigate complex menus.
Accounting and PHR interaction: To truly see the potential of success for these solutions, we can consider some of the currently used cases that NUANCE has been exhibiting. In looking at it from a health care perspective, patients would have the ability to simply ask to schedule a visit without having to call. A patient also has the ability to call to refill their medication.
Nuance did address some of the security concerns by providing tools such as VocalPassword that will tackle authentication. This would help verify the identity of patients who are requesting services and giving commands. As more intelligence voice-driven systems mature, the areas to focus on will be operational costs, customer satisfaction, and data capture.
[...] medical practice billing software encourage [...]
I’ve been interested in the new “wearables” segment for a while. I reached out to Cameron Graham, the managing editor at TechnologyAdvice where he oversees market research for emerging technology, to give us some evidence-driven advice about wearables that entrepreneurs, innovators, healthcare providers, and payers can use for decision making. Specifically, what does the current research show and what are the actionable insights for how to incentivize patients to use them and figure out why patients might pay for them? Cameron thinks that wearable health technology could help improve patient outcome monitoring, if insurance companies and providers work together. He elaborated:
Wearable health technology (or mHealth as some call it) is one of the emerging frontiers in medicine. Fitness tracking devices could allow the healthcare industry to better measure patient outcomes, monitor patient populations for emerging trends, and give preventative healthcare advice based on quantitative measurements (such as daily step counts or heart-rate). We surveyed 979 US adults about their fitness tracking habits, in order to determine current the usage rate for this technology. We then further surveyed 419 of those adults, who identified as non-trackers, about what incentives would convince them to use wearable health monitors. Here are some of our takeaways for vendors and providers:
1. The wearable health market remains small, but is growing steadily
In order to gauge how many adults are currently generating personal health data that would be useful in either patient treatment or preventative medicine, we asked a random, nationwide sample of adults whether they currently tracked their weight, diet, or exercise using a fitness tracking device or smartphone app.
74.9 percent of respondents indicated they did not track any of those variables using either a fitness tracker or smartphone app. 25.1 percent reported tracking such stats.
Out of the roughly one quarter of adults who do track their fitness, 14.1 percent said they used a smartphone app, and 11 percent said they used a fitness tracker. There is currently little data on such demographics, although the Pew Internet Research Project conducted a survey in 2012 looking at similar trends. In their report, they noted that seven percent of adults tracked health indicators using an app. Combining these results, we can see that the market for health tracking applications has approximately doubled over the last two years.
As more consumers adopt such technology, and rely on it for monitoring their health, providers need to become involved in the discussion. There is limited data that can be draw from a sample of just 25 percent of a patient population. If providers can encourage adoption among a majority of their patients however, they will gain greater insight into current health habits, and be able to provide more tailored advice.
2. Physicians can play a large role in encouraging tracking but there are are few incentives in place for them to do so
Looking into what incentives could convince non-tracking adults to use such devices, we found great potential for healthcare providers to encourage tracking habits among their patients. It appears patients want their physicians involved more in monitoring but our healthcare system doesn’t have the right incentives or payment structures available to compensate providers.
48.2 percent of adults said they would use a wearable fitness tracker if their physician provided one. While this may be financially unrealistic for smaller practices, wearable activity trackers (like the FitBit or Jawbone UP) will likely become cheaper as more sophisticated, multi-purpose devices enter the market, such as the forthcoming Apple Watch.
If physicians were able to get half of the three-quarters of non-tracking adults to start measuring their fitness with wearable devices, it would create huge amounts of patient-generated data for the healthcare industry to analyze.
The infrastructure for handling this data is largely in place. The most popular electronic health record provider, Epic Systems, recently announced a partnership with Apple that will allow hospitals to easily integrate wearable data through Apple’s HealthKit platform into patient portals and records.
Promoting the use of such devices should now be a goal for physicians looking to gain greater insight into their patient population. The question would be why Physicians would do this without additional compensation either directly from their patients or indirectly through insurers.
3. Insurance companies and providers need to form partnerships
While a significant portion of adults would use physician-provided devices, health insurance companies may be the ultimate key to promoting widespread fitness tracker adoption.
A total of 57.1 percent of respondents said they would be more likely (or much more likely) to wear a fitness a tracker if they could receive lower health insurance premiums. In fact, this was a more compelling incentive than the possibility of receiving better healthcare advice from their physician (just 44.3 percent of respondents said that would make them more likely to use a tracker).
By agreeing to use a fitness tracker, insurance customers would become eligible for special discounts, perhaps for walking a set number of steps each day, or raising their heartbeat for a certain period of time. Discounts could be given out directly or through an employer.
Some companies are already experimenting with such systems. Humana insurance has a new Vitality program that allows employees to opt-in to fitness tracking in exchange for possible discounts. Car insurance companies have also found success by offering lower rates for safe-driving, as measured through in-car tracking devices.
If providers want to encourage fitness and health tracking among their patients, they should evaluate the possibility of providing devices to their patients, either for free or at a reduced cost. At the very least, they should make patients aware of the benefits of such devices, and encourage them to automatically share such data through their patient portal.
Long term, providers will likely need to collaborate with insurance companies in order to establish a data sharing system for such information, which can allow for physicians to better monitor their patient population, and provide more accurate, tailored diagnoses. A universal patient record system would be ideal, although given current interoperability standards, an insurance-provider arrangement is more likely.
MedCityNews invited me to attend their ENGAGE “Innovation in Patient Engagement” Conference and I found the content, speakers, and overall quality quite good. Since I chair several conferences every year I know how hard it is to pull off a good one so I’d like to congratulate MedCityNews for pulling off a great event. I asked HITSphere‘s Vik Subbu, our Digital Health editor that focuses on Bio IT and Pharma IT, to summarize what we learned at the event. Here’s Vik’s recap of the conference:
The goal of the ENGAGE was to highlight the importance of patient awareness and engagement in developing and managing novel digital health innovations. The conference was attended by industry experts from various disciplines ranging from academic hospitals, non-profit organizations, digital health start-ups, venture capital, service providers and pharmaceutical companies. The interactions between product developers and patients proved to be worthwhile as it is often rare to get both ends of the spectrum together. The point of the conference, driven home in almost every session, was that having patient (i.e. customer) input early on shapes better product development decisions and viewpoints.
Top Nine Insights for digital health innovators and providers:
Did you attend ENGAGE? What did you learn? Please share your thoughts below.
It’s getting easier and easier to build unregulated software these days but it’s still pretty hard to create regulated/certified systems such as EHRs, medical device software, and government IT. To help create better systems we all know we need better user requirements; however, “heavyweight requirements” efforts have been shunned, especially in unregulated systems, over the past decade in favor of “user stories” and more agile specifications. But, are agile user stories the best way to go in regulated systems where requirements traceability and safety analysis is a must? I invited Abder-Rahman Ali, currently pursuing his Medical Image Analysis Ph.D. in France, to come back and give us advice on whether there’s room for both user stories and SRSs in regulated industries or if we’re stuck with formal requirements specs. The following is Abder-Rahman’s third installment for this blog and I’m excited he’ll be tackling such an important topic. As always, he can be reached via e-mail or twitter. Here’s what Abder-Rahman says about User Stories vs. Software Requirements Specifications:
It was on February, 2001, when seventeen practitioners formed what was called The Agile Manifesto. It seems that since then, we started to hear of the term User Story, although, as will be shown below, it seems that the term appeared before that date.
The questions that may pop-up on someone’s head are, is the User Story just a fancy name to the user requirement? Or, it is actually a new mindset of thinking in the way of dealing with user requirements?
Referring to Wikipedia about the history of user stories, I found that user stories originated with Extreme Programming (XP), but, it wasn’t until 2001, when Ron Jeffries proposed the Three C’s formula: Card, Conversion, Confirmation, where the components of the user stories were captured.
But, what are User Stories after all?
I really liked how Mike Cohn described User Stories, when he said:
User Stories are short, simple description of a feature told from the perspective of the person who desires the new capability, usually a user or customer of the system. They typically follow a simple template:
As a <type of user>, I want <some goal> so that <some reason>.
User Stories are often written on index cards or sticky notes, stored in a shoe box, and arranged on walls or tables to facilitate planning and discussion. As such, they strongly shift the focus from writing about features to discussing them. In fact, these discussions are more important than whatever text is written.
Before moving ahead, and comparing User Stories with Software Requirements Specifications (SRS), let us see how SRS is defined. Based on Chambers, SRS describes the essential behavior of a software product from a user’s point of view, where the purpose of SRS is to be a basis for agreement between the customers and the suppliers on what the software product is to do; a basis for developing the software design; a basis for estimating costs and schedules; a baseline for validation and verification; reducing the development effort; facilitating transfer; and serves as a basis for enhancement.
After knowing what they mean, how can we compare User Stories with SRS? I saw that rather than bringing theory to this part, why not monitor some discussions related to this issue? I thus went through some discussions at a Programmers Stack Exchange thread, and came up with the following:
One of the people involved in the discussion mentioned: To be honest, after spending close to two years immersed in Agile development, I still think “User Story” is just a fancy term for “functional requirement”. That person continues: What User Stories almost never capture, in my experience, are non-functional requirements like performance and security. These kinds of requirements are very difficult to write properly and the format of the User Story simply isn’t very good for capturing them, because they’re more about general product quality and mitigating (but not eliminating) risks rather than meeting a specific user’s need. So, I really think of User Stories as a subset of requirements, with a specific formula, and still use the terms pretty much interchangeably. The one major advantage User Stories do have over requirements is that the word “requirement” suggests that a feature is required where it is often just desired. User Stories can in theory be prioritized and slotted in for any release, whereas requirements appear to be a prerequisite for every release.
Other opinions arise mentioning that SRS focuses on “how” the user interacts with the system, and “how” to implement the functionality. On the other hand, User Stories focus on “what” (interaction between user and system) purpose do features have, such that, the task of a User Story would be a functional requirement, and is the expected work product after the functional tasks have all been completed. Thus, they are completely different things.
Requirements assume that the design of the application is done beforehand, and development is considering the implementation of that design.
User Stories insist that the design of the product is done at the last minute, and is a collaboration between a product person and a developer person, and the details are decided during implementation.
So, as can be noticed, the amount of details provided is different using the two approaches, such that, in the User Story for instance, there is a lot of information that is available not available in the requirement, namely, what is we are trying to achieve with the feature.
Others go and mention that a functional requirement is a formal specification that allows one to know exactly if the software works or not. Whilst a User Story is an informal way to describe a need of one of the User Stories, such that, it doesn’t specify a rigid specification to determine if the software is valid or invalid. Although you can test some part of the User Story, its real completion is when the user says : “Yes, this solves my problem”.
We thus realize that the User Story is a huge paradigm shift in the way to approach the work to be done. A contract here is not made, rather, you are trying to help your user to solve a problem. If you don’t see your user stories as discussion tools with a real user, then you are actually not using User Stories.
This post can grow bigger and bigger, and seems that when people attempt describe the notions “User Story” and “user requirement”, such descriptions come from their experience, and how they use each of them. Going through the comparisons above may not reveal clearly the differences between both terms. For that, we chose to interview Agile experts about this issue, for which answers will be shown in the next post.
Stay tuned until then, and don’t hesitate to share your views in this topic, and how you approach those two terms.
“Large collections of electronic patient records have long provided abundant, but under-explored information on the real-world use of medicines. But when used properly these records can provide longitudinal observational data which is perfect for data mining,” Duan said. “Although such records are maintained for patient administration, they could provide a broad range of clinical information for data analysis. A growing interest has been drug safety.”
In this paper, the researchers proposed two novel algorithms—a likelihood ratio model and a Bayesian network model—for adverse drug effect discovery. Although the performance of these two algorithms is comparable to the state-of-the-art algorithm, Bayesian confidence propagation neural network, by combining three works, the researchers say one can get better, more diverse results.
I saw this a few weeks ago, and while I haven't had the time to delve deep into the details of this particular advance, it did at least give me more reason for hope with respect to the big picture of which it is a part.
It brought to mind the controversy over Vioxx starting a dozen or so years ago, documented in a 2004 article in the Cleveland Clinic Journal of Medicine. Vioxx, released in 1999, was a godsend to patients suffering from rheumatoid arthritic pain, but a longitudinal study published in 2000 unexpectedly showed a higher incidence of myocardial infarctions among Vioxx users compared with the former standard-of-care drug, naproxen. Merck, the patent holder, responded that the difference was due to a "protective effect" it attributed to naproxen rather than a causative adverse effect of Vioxx.
One of the sources of empirical evidence that eventually discredited Merck's defense of Vioxx's safety was a pioneering data mining epidemiological study conducted by Graham et al. using the live electronic medical records of 1.4 million Kaiser Permanente of California patients. Their findings were presented first in a poster in 2004 and then in the Lancet in 2005. Two or three other contemporaneous epidemiological studies of smaller non-overlapping populations showed similar results. A rigorous 18-month prospective study of the efficacy of Vioxx's generic form in relieving colon polyps showed an "unanticipated" significant increase in heart attacks among study participants.
Merck's withdrawal of Vioxx was an early victory for Big Data, though it did not win the battle alone. What the controversy did do was demonstrate the power of data mining in live electronic medical records. Graham and his colleagues were able to retrospectively construct what was effectively a clinical trial based on over 2 million patient-years of data. The fact that EMR records are not as rigorously accurate as clinical trial data capture was rendered moot by the huge volume of data analyzed.
Today, the value of Big Data in epidemiology is unquestioned, and the current focus is on developing better analytics and in parallel addressing concerns about patient privacy. The HITECH Act and Obamacare are increasing the rate of electronic biomedical data capture, and improving the utility of such data by requiring the adoption of standardized data structures and controlled vocabularies.
We are witnessing the dawning of an era, and hopefully the start of the transformation of our broken healthcare system into a learning organization.
I believe if we reduce the time between intention and action, it causes a major change in what you can do, period. When you actually get it down to two seconds, it’s a different way of thinking, and that’s powerful. And so I believe, and this is what a lot of people believe in academia right now, that these on-body devices are really the next revolution in computing.
I am convinced that wearable devices, in particular heads-up devices of which Google Glass is an example, will be playing a major role in medical practice in the not-too-distant future. The above quote from Thad Starner describes the leverage point such devices will exploit: the gap that now exists between deciding to make use of a device and being able to carry out the intended action.
Right now it takes me between 15 and 30 seconds to get my iPhone out and do something useful with it. Even in its current primitive form, Google Glass can do at least some of the most common tasks for which I get out my iPhone in under five seconds, such as taking a snapshot or doing a Web search.
Closing the gap between intention and action will open up potential computing modalities that do not currently exist, entirely novel use case scenarios that are difficult even to envision before a critical mass of early adopter experience is achieved.
The Technology Review interview from which I extracted the quote raises some of the potential issues wearable tech needs to address, but the value proposition driving adoption will soon be truly compelling.
I'm adding some drill-down links below.
Practices tended to use few formal mechanisms, such as formal care teams and designated care or case managers, but there was considerable evidence of use of informal team-based care and care coordination nonetheless. It appears that many of these practices achieved the spirit, if not the letter, of the law in terms of key dimensions of PCMH.
One bit of good news about the Patient Centered Medical Home (PCMH) model: here is a study showing that in spite of considerable challenges to PCMH implementation, the transformations it embodies can be and are being implemented even in small primary care practices serving disadvantaged populations.
We are delighted to introduce our new series of Health Insights. These free to attend events for healthcare professionals feature interactive round table activities, news on how the latest innovations support the health and care community, and best practice experiences from NHS Trust colleagues.
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Starting in Leeds and Newbury this October and held in association with NHS England, each one day conference will feature:
Digital Discovery Sessions
- facilitated round tables exploring procurement issues
An update from NHS England on Tech Funds and Open Source Programme
Host Roy Lilley, popular Healthcare Broadcaster, with lively panel debates
Speakers will include Rob Webster, CEO of NHS Confederation, Tim Straughan, Director of Health and Innovation at Leeds and Partners, and Clive Kay, Chief Executive of Bradford Teaching Hospitals.
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We hope to see you at your local Health Insights.
Twitter, like the Internet in general, has become a vast source of and resource for health care information. As with other tools on the Internet it also has the potential for misinformation to be distributed. In some cases this is done by accident by those with the best intentions. In other cases it is done on purpose such as when companies promote their products or services while using false accounts they created.
In order to help determine the credibility of tweets containing health-related content I suggest the using the following checklist (adapted from Rains & Karmikel, 2009):
Ultimately it is up to the individual to determine how to use health information they find on Twitter or other Internet sources. For patients anecdotal or experiential information shared by others with the same illness may be considered very credible. Others conducting research may find this a less valuable information source. Conversely a researcher may only be looking for tweets that contain reference to peer-reviewed journal articles whereas patients and their caregivers may have little or no interest in this type of resource.
Rains, S. A., & Karmike, C. D. (2009). Health information-seeking and perceptions of website credibility: Examining Web-use orientation, message characteristics, and structural features of websites. Computers in Human Behavior, 25(2), 544-553.
The altmetric movement is intended to develop new measures of production and contribution in academia. The following article provides a primer for research scholars on what metrics they should consider collecting when participating in various forms of social media.
If you participate on Twitter you should be keeping track of the number of tweets you send, how many times your tweets are replied to, re-tweeted by other users and how many @mentions (tweets that include your Twitter handle) you obtain. ThinkUp is an open source application that allows you to track these metrics as well as other social media tools such as Facebook and Google +. Please read my extensive review about this tool. This service is free.
You should register with a domain shortening service such as bit.ly, which will provide you with an API key that you can enter into applications you use to share links. This will provide a means to keep track of your click-through statistics in one location. Bit.ly records how many times a link you created was clicked on, the referrer and location of the user. Consider registering your own domain name and using it to shorten your tweets as a means of branding. In addition, you can use your custom link on electronic copies of your CV or at your own web site. This will inform you when your links have been clicked on. You should also consider using bit.ly to create links used at your web site, providing you with feedback on which are used the most often. For example, all of the links in this article were created using my custom bit.ly domain. In addition, you can tweet a link to any research study you publish to publicize as well as keep track of how many clicks are obtained. Bit.ly is a free service.
Another tool to measure your tweets is TweetReach. This service allows you to track the reach of your tweets by Twitter handle or tweet. It provides output in formats that can be saved for use elsewhere (Excel, PDF or the option to print or save your output by link). To use these latter features you must sign up for an account but the service is free.
Buffer is a tool that allows you to schedule your tweets in advance. You can also connect Buffer to your bit.ly account so links used can be included in your overall analytics. Although Buffer provides its own measures on click-through counts this can contradict what appears in bit.ly. This service is free but also has paid upgrade options available that provide more detailed analytics.
Google Scholar Citation Profile
You can set up a profile with Google Scholar based on your publication record. The metrics provided by this service include a citation count, h-index and i10-index. When someone searches your name using Google Scholar your profile will appear at the top before any of the citations. This provides a quick way to separate your articles from someone else who has the same name as you.
Google Feedburner for RSS feeds
If you maintain your own web site and use RSS feeds to announce new postings you can also collect statistics on how many times your article is clicked on. Feedburner, recently acquired by Google provides one way to measure this. You enter your RSS feed ULR and a report is generate, which can be saved in CVS format.
Journal article download statistics
Many journals provide statistics on the number of downloads of articles. Keep track of those associated with your publication by visiting the site. For example, BioMed Central (BMC) maintains an access count of the last 30 days, one year and all time for each of your publications.
Other means of contributing to the knowledge base in your field include participating on web-based forums or web sites such as Quora. Quora provides threaded discussions on topics and allows participants to both generate and respond to the question. Other users vote on your responses and points are accrued. If you want another user to answer your question you must “spend” some of your points. Providing a link to your public profile on Quora on your CV will demonstrate another form of contribution to your field.
Paper.li is a free service that curates content and renders it in a web-based format. The focus of my Paper.li is the use of technology in Canadian Healthcare. I have also created a page that appears at my web site. Metrics on the number of times your paper has been shared via Facebook, Twitter, Google + and Linked are available. This service is free.
Twylah is similar to paper.li in that it takes content and displays it in a newspaper format except it uses your Twitter feed. There is an option to create a personalized page. I use tweets.lauraogrady.ca. I also have a Twylah widget at my web site that shows my trending tweets in a condensed magazine layout. It appears in the side bar. This free service does not yet provide metrics but can help increase your tweet reach. If you create a custom link for your Twylah page you can keep track of how many people visit it.
Analytics for your web site
Log file analysis
If you maintain your own web site you can use a variety of tools to capture and analyze its use. One of the most popular applications is Google Analytics. If you are using a content management system such as WordPress there are many plug-ins that will add the code to the pages at your site and produce reports. WordPress also provides a built-in analytic available through its dashboard.
If you have access to the raw log files you could use a shareware log file program or the open source tool Piwik. These tools will provide summaries about what pages of your site are visited most frequently, what countries the visitors come from, how long visitors remain at your site and what search terms are used to reach your site.
All of this information should be included in the annual report you prepare for your department and your tenure application. This will increase awareness of altmetrics and improve our ability to have these efforts “count” as contributions in your field.